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Ministry of Health, Costa Rica Responsibility of the Costa Rican State In Costa Rica the right to health is not expressed literally in the Constitution of the Republic. The right to health can be inferred from a combination of constitutional, legal, and international regulations. Gutiérrez, Juan José. The Right to Health in the Americas. PAHO.1989 Garro Vargas, Fabrizio. Constitutional Framework of the Right to Health. UCR.1994 General Health Law Art.1 “The population’s health is a public good protected by the State.”

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Ministry of Health", Costa Rica The right to health includes the right to access to quality health services.

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Rights-based Approach Needs-based ApproachRights-based Approach Individual is a passive recipient. Individual is an active participant. It involves objectives, usually of partial care. It involves the universal care imperative. Needs may be met without guaranteeing continuity. Needs must always be respected. It may be organized hierarchically. Is not organized hierarchically; all rights must be respected. Does not involve responsibilities.Does involve responsibilities. It is connected with a promise.It is connected with obligations. Needs may change according to culture and circumstances. Rights are universal. May be met by charity.Charity is unacceptable. Meeting needs often depends on political will. Meeting needs is compulsory.

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Ministry of Health, Costa Rica It is a given that there are no free health services and, as a result, there are no beneficiaries. The entire population has the right to health services coverage because everyone contributes according to his/her ability.

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Conceptual and Strategic Governance Model for Social Production of Health Ministry of Health, Costa Rica

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Equitably protect and improve the health status of the population. Equitably protect and improve the health status of the population.

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Equitably protect and improve health status of the population. Equitably protect and improve health status of the population. Social Production of Health

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Equitably protect and improve the health status of the population. Equitably protect and improve the health status of the population. National Health System Steering Assurance Financing Health care delivery to the public and protection of the human habitat Social Production of Health

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Health Sector A series of public centralized and decentralized entities that have an explicit and legal responsibility to improve and protect the health status of the population.

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Health Sector Executive Decree No MP Ministry of health, regulatory authority Costa Rican Social Security Fund (CCSS), in areas exclusively pertaining to health Costa Rican Institute of Water Supply and Sewerage Systems (ICAA), in areas exclusively pertaining to health Comprehensive Auditing of Health Services Council on Integrated Care for Children Council on Youth Council on the Elderly Institute for Drug Addiction & Alcoholism (IAFA) Costa Rican Institute for Research and Teaching in Nutrition and Health (INCIENSA) Costa Rican Cancer Institute (ICCC) Occupational Risk Section of the National Insurance Institute Costa Rican Institute of Sports and Recreation (ICODER) (8 May 2006)

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National System of Health Services Consists of a series of interrelated public and private national and international entities whose basic activities include, among other things, the delivery of goods and services (final, intermediate and support), explicitly intended to protect and improve the health status of the population, regardless of whether or not they are for- or not-for profit.

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National Health System (Social Production of Health) Consists of an interrelated series of entities that have a significant impact on the socioeconomic, cultural, environmental, biological, and personal health services dimensions, as well as the determinants of human habitat protection.

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Social Production of Health System The Ministry of Health as the Steering Entity in Health National Health System Ministry of Health

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Steering in health Delivery of health services to the public and services for the protection and improvement of the human habitat Guarantee of insurance for health services to the public and protection and improvement of the human habitat Financing of health care services for the public and services for the protection and improvement of the human habitat Functions of the National Health System Steering: to conduct, lead, guide, order, or exercise authority over a community, group of institutions or people. Steering of the Health Sector: exercise of this governmental authority, management, and leadership over all sector entities (CCSS). Steering of the National Health Services System: process whereby the regulatory authority effectively leads, promotes, and coordinates the efforts of the entities of the National Health System. Steering of the National Health System: process whereby the regulatory authority effectively leads, promotes, and coordinates the efforts of key social actors and exercises its authority in health to protect and improve the health of the population.

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Functions of the National Health System Obligation of the National Health System to guarantee universal access to health services to the population, both for the care of individuals and for protecting and improving the human habitat, with emphasis on the vulnerable sectors of the population, especially the poorest. Steering in health Delivery of health services to the public and services for the protection and improvement of the human habitat Guarantee of insurance for health services to the public and protection and improvement of the human habitat Financing of health care services for the public and services for the protection and improvement of the human habitat

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Perspectives on Insurance Public perspective: The establishment, based on needs, performance, and impact criteria, of health services for individuals and services for the protection and improvement of the human habitat that cover the entire population grounded in the principles of equity and solidarity. Social perspective: A series of actions designed to guarantee the right of the population to receive the package of health care services and human habitat protection and improvement services established for the public. Financing perspective: Mechanism for protecting the people against the risk of disease and death by guaranteeing the availability of funds so that each individual has access to health services, when needed, without payment for services rendered.

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Functions of the National Health System A series of actions whereby the State, an insurance entity, or another public or private agency collects, administers, and allocates the necessary financial resources for producing or acquiring the health goods and services for the public and the human habitat protection and improvement services that should be provided to the population. Steering in health Delivery of health services to the public and services for the protection and improvement of the human habitat Guarantee of insurance for health services to the public and protection and improvement of the human habitat Financing of health care services for the public and services for the protection and improvement of the human habitat

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Functions of the National Health System The act of providing or delivering the basic package of health services established; this includes granting individual and community health care services, in addition to services meant to protect and improve the human habitat. Steering in health Delivery of health services to the public and services for the protection and improvement of the human habitat Guarantee of insurance for health services to the public and protection and improvement of the human habitat Financing of health care services for the public and services for the protection and improvement of the human habitat

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STEERING OF THE SOCIAL PRODUCTION OF HEALTH Ministry of Health, Costa Rica

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Health Surveillance Steering function, whereby the public health status, its determinants, and trends are identified, analyzed, and monitored in a continuous, systematic, multidisciplinary, intersectoral, and participatory fashion to contribute to the timely selection of the most appropriate measures for protecting and improving the health of the population.

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Health Policy Orientation Steering function exercised by the Minister of Health or his/her representatives (Vice Minister of Health, Director General, Directors of Steering Regions and of Steering Areas), which includes the definition of priorities and directives, spearheading strategic actions and securing resources and, in order to ensure the desired impact, negotiating directly with the social actors of the system for the Social Production of Health.

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Health Marketing Steering function whereby the Ministry of Health takes the necessary action to persuade or motivate the social actors that directly or indirectly impact the population health status to adopt and implement the health promotion strategy. By performing this function, the Ministry directly influences public and private organizations and, principally, the general population, with an emphasis on excluded groups, to adopt a culture of non-exclusion and demand their right to participate in decision-making, as well as in the definition, implementation, control, and evaluation of activities aimed at protecting and improving the community’s health status.

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Strategic Health Planning Steering function, whereby concerted goals and objectives are defined on the basis of a sound health situation analysis to bring about continuous improvements in public health; also, whereby the necessary strategies, actions, and resources for reaching the target are defined, negotiated, and agreed to with key social actors.

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Health Regulation Function of the State (exercised by the Ministry of Health) that consists of defining, enacting, interpreting, applying, and controlling the regulatory framework that should apply to every individual and legal entity that provides or receives health-related goods and services; or that engages in activities or performs acts that, by nature, may have an impact on the population’s health.

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Orientation/Modulation of Health Financing Steering function that consists of correcting deviations from government priorities in the financing of health services for the public and of services for the protection and improvement of the human habitat; and in ensuring that the different financing modalities for public and private services complement one another.

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Function that consists of: defining the basic package of health services for the public and the services for human habitat protection that should be guaranteed by the State; determining the model through which those services are delivered and promoting coordination and complementary activities among the various public and private providers to guarantee equitable access to the public, regardless of the institution or system to which they belong or have been assigned to or that provides them services. Source: Based on PAHO. Armonización de la Provisión de Servicios de Salud:. Discussion Paper for the Expert Meeting, Washington, D.C., June 2001 Harmonizing Health Services Delivery

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Impact Assessment of Actions in Health Function whereby a systematic, multidisciplinary, intersectoral, and participatory impact assessment is made of the priority actions in public health as they pertain to the health determinants and health status of the population to support strategic and timely decision- making.

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Ministry of Health, Costa Rica Ministry of Health Steering of the Health Services of the Costa Rican Social Security Fund Health Policy Orientation Setting priorities and establishing political guidelines, assisting with the implementation of strategic actions and advocacy for securing resources. Marketing of Health Positioning the health promotion strategy in the CCSS health services and the culture of non- exclusion among the institution’s staff. Health Surveillance Monitoring the coverage and quality of CCSS health services and their determinants. Strategic Health Planning Setting priority goals and objectives for implementation of the national health services policy and developing plans, programs, and projects for attaining these goals and objectives. Regulating Health Defining and controlling the health services regulatory framework.

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Ministry of Health Steering of the Health Services of the Costa Rican Social Security Fund Orientation/Modulati on of Health Financing Approval and monitoring of the funding allocated in the CCSS for addressing the priorities set in the National Health Policy and determining corrective measures when deviations are found. Harmonization of Health Services Harmonization of CCSS health services with other the services of other providers. Impact Assessment of Health Actions Assessment of the impact of the priority plans, programs, and projects of the CCSS related to national health policy.

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Strategies for Operationalizing Steering in Health  Health sector reform: Separating the steering and health service delivery functions.  Identifying the roles of National Health System institutions in terms of the steering, insurance, financing, and service delivery functions.  Intensifying the decentralization of the Ministry of Health.  Separation and complementation of central, regional, and local functions.

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Strategies for Operationalizing Steering in Health  Design and dissemination of the Conceptual and Strategic Model for Steering of the Social Production of Health.  Steering based more on leadership than on “legal authority.”  Adjustment of the Ministry of Health’s Strategic Framework.  Implementation of organizational development: functions – products - processes – procedures - structural adjustment - human resource profiles.

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The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low, and achieving our mark. Miguel Angel (Paraphrased from: daily inspiration from The Monk who Sold his Ferrari: A spiritual fable… By: Robin S. Sharma)